Hysteroscopic Endometrial Ablation: From Indications to Instrumentation and Techniques-A Call to Action.

The development of minimally invasive techniques has led to the creation of innovative alternatives in cases where traditional methods are not applicable. In modern gynecology, hysteroscopy has become the gold standard for the evaluation and treatment of intrauterine pathology. Endometrial ablation (EA) is a procedure that uses different types of energy to destroy the endometrium and is currently used as an alternative technique in cases of heavy menstrual bleeding when medical treatment has failed and uterine preservation is desired. The aim of this review was to evaluate the feasibility, safety, and clinical outcomes of hysteroscopic EA as an alternative in patients with abnormal uterine bleeding. A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and Cochrane Library), from 1994 to June 2022, to evaluate the outcomes in patients with abnormal uterine bleeding (AUB) undergoing EA using hysteroscopic and non-hysteroscopic techniques. Only scientific publications in English were included. Twelve articles on the current use of endometrial ablation were included. Data on patient symptoms, tools used for EA, primary outcomes, and adverse events were recorded. EA should be considered an effective and safe approach in the management of patients with abnormal uterine bleeding caused by benign pathology, in whom medical treatment has failed or is contraindicated. Due to the lack of evidence, it would be interesting to determine whether EA would also have a role in the treatment of women with premalignant lesions, avoiding invasive surgical procedures or medical treatment in those patients for whom hysterectomy or the use of hormonal treatment is contraindicated.

HYSTEROSCOPIC MYOMECTOMY.

Leiomyomas are the most common pelvic tumors. Submucosal fibroids are a common cause of abnormal bleeding and infertility. Hysteroscopic myomectomy is the definitive management of symptomatic submucosal fibroids, with high efficacy and safety. Several techniques have been introduced over time and will be covered in depth in this manuscript. Advances in optics, fluid management, electrosurgery, smaller diameter scopes, and tissue removal systems, along with improved training have contributed to improving the safety and efficiency of hysteroscopic myomectomy.

Virtual sonographic hysteroscopy in assisted reproduction: A retrospective cost-effectiveness analysis.

OBJECTIVE: To analyze the cost-effectiveness of virtual sonographic hysteroscopy (VSH) performed before in vitro fertilization (IVF) (Scenario 1), frozen embryo transfer (Scenario 2), and oocyte donation (Scenario 3) attempts. METHODS: A retrospective analysis of data extracted from patients' files was conducted. Before undergoing the assigned treatment, VSH was offered to all patients. Cost-effectiveness was calculated on the basis of cost per live birth. The total cost was compared with a control group of patients who declined to have hysteroscopy before their treatment. RESULTS: A total of 292 women were involved. Virtual sonographic hysteroscopy was performed in 192 women. Conventional operative hysteroscopy was subsequently required in 34 of them (17.7%). Subsequent assisted reproduction attempts resulted in live birth in 111 women-34/69 (49.3%), 35/69 (50.7%), and 42/54 (77.8%) in Scenarios 1, 2, and 3, respectively. This compared favorably with 100 women who declined VSH, with live birth achieved in 15/39 (38.5%), 14/37 (37.8%), and 15/24 (62.5%) in Scenarios 1, 2, and 3, respectively. The overall cost-effectiveness of VSH compared favorably with straightforward treatment performed without this test. CONCLUSION: The overall cost-effectiveness of treatment attempts carried out after previous VSH compared favorably with straightforward treatment performed without this test.

Hysteroscopic management of intrauterine benign diseases.

Hysteroscopy is the gold-standard procedure for evaluating the vagina, cervix, cervical canal and uterine cavity, with a great possibility of identifying lesions and being able to treat them at the same time in a 'See and Treat' procedure. The presence of the operative channel allows directed biopsy and excision of part of the lesions. Hysteroscopic treatment can be offered in office and hospital settings. The main difference is the use of anesthesia for hospital hysteroscopy. Office hysteroscopy has as major challenge the patient's pain threshold and the size of the lesion base. The use of the appropriate technique allows the removal of lesions even in an outpatient setting. Hospital hysteroscopy allows the use of instruments with a larger diameter and with the use of associated energy. The development of new technologies has increased the spectrum of office hysteroscopy.

Reproductive outcomes of infertile women undergoing "see and treat" office hysteroscopy: a retrospective observational study.

INTRODUCTION: This study aimed to assess the feasibility and efficacy of office hysteroscopy to diagnose and treat the specific uterine pathologies frequently diagnosed and thought to be associated with female infertility. MATERIAL AND METHODS: Using office hysteroscopy, we examined the uterine cavity in women with primary or secondary infertility and evaluated the reproductive outcomes of those affected by one or more pathologies, including cervico-isthmic adhesions, intrauterine polyps and intrauterine adhesions. Additional patient characteristics considered were age and parity, uterine pathology, pain during hysteroscopy, and outcomes including spontaneous pregnancies achieved and time between treatment and pregnancy. RESULTS: Reproductive outcomes of 200 patients affected by one or more uterine pathologies were evaluated. Cervico-isthmic adhesions were the most frequent findings in older women, with nearly 80% of them achieving pregnancy sooner than the others in our study. Spontaneous pregnancy rates following office hysteroscopy were 76%, 53% and 22% in women with cervico-isthmic adhesions, polyps (< 5 mm) and intrauterine adhesions, respectively. CONCLUSIONS: Office hysteroscopy is a feasible and highly effective diagnostic and therapeutic procedure for cervico-isthmic and intrauterine adhesions, as well as for small polyps, allowing the resolution of female infertility related to these pathologies, without trauma and with only minimal discomfort.

Pain management for in-office hysteroscopy. A practical decalogue for the operator.

Hysteroscopy is known to be the gold standard for evaluation of intrauterine pathologies, pre-menopausal and post-menopausal abnormal uterine bleeding and, in addition to this, it is a crucial examination in the infertility work-up. In-office operative hysteroscopy incorporates the outstanding possibility of seeing and treating an intracavitary pathology in the same examination, eliminating all the risk related to anesthesia and reducing procedure-related costs. By now, performing operative procedures in the office setting is recognized as feasible and safe. Over the last 20 years, many efforts have been made to implement the in-office operative approach worldwide. However, for some women, in-office hysteroscopy is still considered a painful experience, with reported discomfort at different steps of the hysteroscopic procedures. Moreover, uneventful and tedious sensations might be increased by a high level of anxiety for such examination. For this reason, despite the feasibility of the in-office approach, many clinicians are still afraid of provoking pain during the procedure and rather not to perform surgical procedures in the office, postponing the removal of the pathology in the operating room. To date, there is no consensus concerning pain management for in-office hysteroscopy and different approaches, pharmacological and non-pharmacological aids, as well as several procedural tips and tricks are utilized. Our purpose is to provide a feasible practical decalogue for the operator, to supply adequate management of pain during in-office hysteroscopic procedures, performing challenging operations, shrinking discomfort, aiming to upgrade both women's and operator's satisfaction.

Results of the Insertion of Hysteroscopic Sterilization Devices in a Brazilian Public Hospital.

OBJECTIVE: To evaluate the insertion of the hysteroscopic intratubal sterilization device for female sterilization concerning the technique and the feasibility. METHODS: Retrospective study with data collection of medical records of 904 patients who underwent device insertion between January and September 2016 in a public hospital in Rio de Janeiro (Brazil) with data analysis and descriptive statistics. RESULTS: In 85.8% of the cases, the uterine cavity was normal, and the most commonly-described findings upon hysteroscopy were synechiae (9.5%). The procedure lasted an average of 3.56 minutes (range: 1 to 10 minutes), and the pain was considered inexistent or mild in 58,6% of the cases, mild or moderate in 32,8%, and severe or agonizing in less than 1% (0.8%) of the cases, based on a verbal scale ranging from 0 to 10. The rate of successful insertions was of 85.0%, and successful tubal placement was achieved in 99.5% of the cases. There were no severe complications related to the procedure, but transient vasovagal reactions occurred in 5 women (0.6%). CONCLUSION: Female sterilization performed by hysteroscopy is a safe, feasible, fast, and well-tolerated procedure. The rates of successful insertions and tubal placements were high. There were few and mild adverse effects during the procedure, and there were no severe complications on the short term.

OBJETIVO: Avaliar a inserção de dispositivo intratubário de esterilização histeroscópica com relação à viabilidade e à técnica. MéTODOS: Estudo retrospectivo com coleta de dados de prontuários das pacientes submetidas à inserção do dispositivo entre janeiro e setembro de 2016 em um hospital público do Rio de Janeiro, com análise dos dados e realização de estatísticas descritivas. RESULTADOS: Foram incluídos 904 casos no estudo. Em 85,8% dos casos, a cavidade uterina estava normal, e os achados mais comumente descritos à histeroscopia foram as sinequias (9,5%). O tempo médio do procedimento foi de 3,56 minutos (gama: de 1 a 10 minutos); a dor foi considerada de ausente a leve em 58,6% dos casos, de leve a moderada em 32,8% dos casos, e de forte à pior dor possível em menos de 1% dos casos (0,8%). A taxa de inserções bem-sucedidas foi de 85,0%, e a colocação tubária foi bem-sucedida em 99,5% dos casos. Não foram identificadas complicações graves, mas reações vasovagais transitórias ocorreram em 5 mulheres (0,6%). CONCLUSãO: A esterilização feminina por histeroscopia é um procedimento seguro, viável, rápido, e bem tolerado. As taxas de inserção bem-sucedida e de colocação tubária foram altas. Houve poucos e leves efeitos colaterais durante o procedimento, e não foram observadas complicações graves no curto prazo.

Results of the insertion of hysteroscopic sterilization devices in a brazilian public hospital / Resultados da inserção de dispositivos de esterilização histeroscópica em um hospital público brasileiro

Abstract Objective To evaluate the insertion of the hysteroscopic intratubal sterilization device for female sterilization concerning the technique and the feasibility. Methods Retrospective study with data collection of medical records of 904 patients who underwent device insertion between January and September 2016 in a public hospital in Rio de Janeiro (Brazil) with data analysis and descriptive statistics. Results In 85.8% of the cases, the uterine cavity was normal, and themost commonlydescribed findings upon hysteroscopy were synechiae (9.5%). The procedure lasted an average of 3.56minutes (range: 1 to 10minutes), and the pain was considered inexistent or mild in 58,6% of the cases, mild or moderate in 32,8%, and severe or agonizing in less than 1% (0.8%) of the cases, based on a verbal scale ranging from 0 to 10. The rate of successful insertions was of 85.0%, and successful tubal placement was achieved in 99.5% of the cases. There were no severe complications related to the procedure, but transient vasovagal reactions occurred in 5 women (0.6%). Conclusion Female sterilization performed by hysteroscopy is a safe, feasible, fast, and well-tolerated procedure. The rates of successful insertions and tubal placements were high. There were few and mild adverse effects during the procedure, and there were no severe complications on the short term.

Resumo Objetivo Avaliar a inserção de dispositivo intratubário de esterilização histeroscópica com relação à viabilidade e à técnica. Métodos Estudo retrospectivo com coleta de dados de prontuários das pacientes submetidas à inserção do dispositivo entre janeiro e setembro de 2016 emumhospital público do Rio de Janeiro, comanálise dos dados e realização de estatísticas descritivas. Resultados Foram incluídos 904 casos no estudo. Em 85,8% dos casos, a cavidade uterina estava normal, e os achados mais comumente descritos à histeroscopia foram as sinequias (9,5%). O tempomédio do procedimento foi de 3,56minutos (gama: de 1 a 10 minutos); a dor foi considerada de ausente a leve em 58,6% dos casos, de leve a moderada em32,8% dos casos, e de forte à pior dor possível emmenos de 1% dos casos (0,8%). A taxa de inserções bem-sucedidas foi de 85,0%, e a colocação tubária foi bemsucedida em 99,5% dos casos. Não foram identificadas complicações graves, mas reações vasovagais transitórias ocorreram em 5 mulheres (0,6%). Conclusão A esterilização feminina por histeroscopia é um procedimento seguro, viável, rápido, e bem tolerado. As taxas de inserção bem-sucedida e de colocação tubária foram altas. Houve poucos e leves efeitos colaterais durante o procedimento, e não foram observadas complicações graves no curto prazo.

Updates in office hysteroscopy: a practical decalogue to perform a correct procedure.

Nowadays, hysteroscopy is the gold standard for the diagnosis and treatment of intrauterine pathologies as it represents a safe and minimally invasive procedure that allows the visualization of the entire uterine cavity. Numerous technological innovations have occurred over the past few years, contributing to the development and widespread use of this technique. In particular, the new small-diameter hysteroscopes are equipped with an operating channel in which different mechanical instruments can be inserted, and they allow not only to examine the cervical canal and uterine cavity but also to perform biopsies or treat benign diseases in a relatively short time without anesthesia and in an outpatient setting. In this scenario, the operator must be able to perform hysteroscopy in the correct way to make this procedure increasingly safe and painless for the patient. This review aims to describe the ten steps to perform a correct office hysteroscopy, starting from patient counseling to the therapy after the procedure.

From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis.

PURPOSE: To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications. METHODS: PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology. RESULTS: We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%). CONCLUSIONS: We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5 mm) and when hysteroscopic treatment is inconclusive.

The role of leiomyomas in the genesis of abnormal uterine bleeding (AUB).

Abnormal uterine bleeding (AUB) is the major complaint in approximately one-third of gynecological visits in premenopausal women, and in >70% of appointments of perimenopausal and postmenopausal women. Uterine myoma is one of the main causes of AUB during menacme, especially when it is submucosal. The association of myoma and AUB may be related to several factors, from local alterations of angiogenic and vasoactive substances to changes in uterine contractility. The objective of this paper is to show the different associations of myoma and AUB.

The value of hysteroscopic biopsy in the diagnosis of endometrial polyps.

Several studies have demonstrated that the combination of hysteroscopy with endometrial biopsy is more accurate in differentiating endometrial polyps from endometrial hyperplasia and cancer. However, blind biopsy not always confirms hysteroscopic findings due to high rates of inadequate or insufficient material. The objective of this clinical, prospective, and comparative study was to establish a correlation between the histological results of office-based endometrial biopsies (hysteroscopically guided and blind) with the surgical polypectomy specimens. We evaluated 82 patients with hysteroscopic diagnosis of endometrial polyp, who randomly underwent hysteroscopically guided biopsy or blind biopsy, referred for surgical resection. A total of 36 women (43.9%) underwent hysteroscopically guided biopsy and 46 women (56.1%) underwent blind biopsy. The sensitivity of hysteroscopically guided biopsy for the diagnosis of endometrial polyps ranged between 35.3 and 36.8%, when carried out at the apex and base of the lesion, compared with 29.2% for blind biopsy. Specificity was 33.3, 50, and 60%, respectively, for each biopsy. The positive predictive values were 75, 77.8, and 87.5%, and negative predictive values were 8.3, 14.3, and 8.1% respectively, compared with surgical polypectomy specimens. The office-based endometrial biopsies had low diagnostic accuracy for endometrial polyps compared with surgical polypectomy specimens.

Percutaneous core biopsy of palpable breast lesions: accuracy of frozen section histopathological exam in the diagnosis of breast cancer.

OBJECTIVE: to evaluate the accuracy of frozen section histopathology from fragments of tissue obtained by percutaneous core needle biopsy of palpable tumors in the diagnosis of breast cancer. METHODS: a cohort study was performed on 57 patients with palpable tumors and suspected breast cancer undergoing percutaneous thick needle core biopsy. The fragments were analyzed by the same pathologist. RESULTS: frozen section diagnosed 16 benign cases (28.6%) and 40 malignant (71.4%), whereas paraffin showed that 15 were benign (26.8%) and 41 malignant (73.2%). Histopathological examinations were concordant in 55 cases and there was one false-negative (6.2%). Statistics rates were: negative predictive value of 93.8%, positive predictive value of 100%, no false-positive (0%), one false negative (6.2%), specificity of 100%, sensitivity of 97 6%; observed agreement = 98.2%; expected agreement = 59.9%, Kappa = 0.955 [ 95% CI = 0.925-0.974, p < 0.01 ]. CONCLUSIONS: frozen section histopathological findings showed excellent correlation with the findings by the technique in paraffin in the fragments of palpable breast tumors obtained by thick needle percutaneous core biopsy (98.2% accuracy). Therefore, in these patients, it was possible to anticipate the diagnosis, staging and the breast cancer treatment planning.

Percutaneous core biopsy of palpable breast lesions: accuracy of frozen section histopathological exam in the diagnosis of breast cancer / Avaliação da acurácia do exame histopatológico por congelação em fragmentos de tecido obtidos por biópsia percutânea com agulha grossa no diagnóstico do câncer de mama em tumores palpáveis

OBJECTIVE: to evaluate the accuracy of frozen section histopathology from fragments of tissue obtained by percutaneous core needle biopsy of palpable tumors in the diagnosis of breast cancer. METHODS: a cohort study was performed on 57 patients with palpable tumors and suspected breast cancer undergoing percutaneous thick needle core biopsy. The fragments were analyzed by the same pathologist. RESULTS: frozen section diagnosed 16 benign cases (28.6%) and 40 malignant (71.4%), whereas paraffin showed that 15 were benign (26.8%) and 41 malignant (73.2%). Histopathological examinations were concordant in 55 cases and there was one false-negative (6.2%). Statistics rates were: negative predictive value of 93.8%, positive predictive value of 100%, no false-positive (0%), one false negative (6.2%), specificity of 100%, sensitivity of 97 6%; observed agreement = 98.2%; expected agreement = 59.9%, Kappa = 0.955 [ 95% CI = 0.925-0.974, p < 0.01 ]. CONCLUSIONS: frozen section histopathological findings showed excellent correlation with the findings by the technique in paraffin in the fragments of palpable breast tumors obtained by thick needle percutaneous core biopsy (98.2% accuracy). Therefore, in these patients, it was possible to anticipate the diagnosis, staging and the breast cancer treatment planning. .

OBJETIVO: avaliar a acurácia do exame histopatológico por congelação em fragmentos de tecido obtidos por biópsia percutânea com agulha grossa no diagnóstico do câncer de mama em tumores palpáveis. MÉTODOS: foi realizado estudo de coorte em 57 pacientes portadoras de tumores palpáveis e suspeitos de câncer de mama, submetidas à biópsia por punção percutânea com agulha grossa. Os fragmentos foram analisados pela mesma anatomopatologista. RESULTADOS: a congelação diagnosticou 16 casos benignos (28,6%) e 40 malignos (71,4%), enquanto a parafina revelou que 15 eram benignos (26,8%) e 41 malignos (73,2%). Os exames histopatológicos foram concordantes em 55 casos e houve um falso-negativo (6,2%). As taxas estatísticas foram: valor preditivo negativo de 93,8%, valor preditivo positivo de 100%, nenhum falso-positivo (0%), um falso-negativo (6,2%), especificidade de 100%; sensibilidade de 97,6%; concordância observada = 98,2%; concordância esperada = 59,9%; Kappa = 0,955 [IC 95% = 0,925 a 0,974, p<0,01]. CONCLUSÃO: Os achados histopatológicos por congelação apresentaram excelente correlação com os achados pela técnica em parafina nos fragmentos de tumores mamários palpáveis obtidos por punção percutânea com agulha grossa (acurácia de 98,2%). Logo, nestas pacientes, foi possível antecipar o diagnóstico, o estadiamento e a programação terapêutica do câncer de mama. .

A new system to classify submucous myomas: a Brazilian multicenter study.

OBJECTIVE: To evaluate 2 different predicting scores of submucous myoma removal, fluid balance, and operative time in woman undergoing hysteroscopic myomectomy. DESIGN: A multicenter and prospective study (Canadian Task Force classification II-2). SETTING: Six hysteroscopy centers in Brazil. PATIENTS: A total of 191 women who underwent hysteroscopic resection of 205 submucous myomas. INTERVENTION: Resection of submucous myomas (hysteroscopic myomectomy). Myomas were scored according to the European Society for Gynaecological Endoscopy (ESGE) and STEPW (size, topography, extension, penetration, and wall) classifications. The validation of the 2 classifications was assessed with sensitivity and specificity of each classification, with their best cutoff point. MAIN OUTCOME MEASURES: To correlate ESGE and STEPW classifications with complete or incomplete removal of submucous myoma, length of surgery, surgical complications, and fluid balance. RESULTS: Removal of the myoma was complete in 190 (92.7%) of 205 myomectomies, and incomplete in 15 (7.3%). All 140 (100%) of 140 myomas with a score ≤ 4 in the STEPW classification were completely removed, and 50 (76.9%) of 65 myomas with a score >4 were removed. All 15 (100%) cases of incomplete hysteroscopic myomectomy had a STEPW score >4. With the ESGE classification, 156/164 (95.1%) cases of type 0 and type 1 myomas, and 34/41 (82.9%) of type 2 were completely resected. STEPW scores >4 were statistically associated with longer duration of surgery, surgical complications, higher levels of fluid balance, and use of gonadotropin releasing hormone analogue if compared with lower scores. The ESGE scores were not associated with any of these variables. CONCLUSION: Classifying submucous myomas with the STEPW classification allows better prediction of myoma removal, fluid balance, length of surgery and surgical complications in hysteroscopic myomectomy than ESGE classification.

Diagram to map the locations of endometriosis.

OBJECTIVE: To develop and test a visual map that corresponds practically and objectively to the anatomical areas affected by endometriosis. METHOD: The study comprised 150 questionnaires concerning 10 clinical cases of endometriosis presented as a visual diagram that were distributed at 3 different scientific events, among 3 groups of 50 gynecologists. Data were analyzed to evaluate the diagram's ability to graphically represent the endometriosis sites. RESULTS: After presentation at the first event, the rate of correct answers on the site of endometriosis was 84.7%; at the second event, after modifications implemented after feedback from the first event, the rate of correct answers was 97.4%; and at the third event, when all suggestions and modifications had been made, the rate was 99.7%. CONCLUSION: The diagram proposed to map the location of endometriosis lesions appears to be an adequate and effective instrument to represent the site of the disease, with correlation at almost 100%.

Polimorfismos nos genes MMP2, MMP13, CYP1A1, GSTM1 e EMX2 e endometriose / Polymorphisms in MMP2, MMP13, CYP1A1, GSTM1 and EMX2 and endometriosis

A endometriose é uma doença que afeta de 10 a 15% das mulheres em idade fértil. Trata-se de uma doença crônica dependente de estrogênio, caracterizada pela presença de tecido endometrial fora da cavidade uterina. É uma doença multifatorial e poligênica que ainda apresenta etiologia desconhecida. Estudos moleculares relacionam a suscetibilidade à endometriose com polimorfismos genéticos específicos. Os principais genes estudados são responsáveis pelos mecanismos biológicos da doença, como por exemplo, metabolismo do estrogênio, receptores hormonais e detoxificação celular. O objetivo do presente artigo é revisar as pesquisas relacionadas aos genes CYP1A1, MMP2, MMP13, GSTM1 e EMX2, para avaliar as possíveis implicações na patogênese da endometriose

Endometriosis is a disease that affects 10 to 15% of women on reproductive age. It is an estrogen-dependent chronic disease, which is characterized by the presence of endometrial tissue outside the uterine cavity. It is a polygenic and multifactorial disease that still has unknown etiology. Molecular studies relate susceptibility to specific genetic polymorphisms with endometriosis. The main studied genes are responsible for the biological mechanisms of disease, such as estrogen metabolism, hormone receptors, and cellular detoxification. The aim of this paper is to review the research related to CYP1A1, MMP2, MMP13, GSTM1, and EMX2 genes, in order to assess the possible implications in the pathogenesis of endometriosis

Feasibility of a new system of classification of submucous myomas: a multicenter study.

OBJECTIVE: To evaluate the performance of the STEPW (size, topography, extension, penetration, wall) classification system in predicting partial or complete fibroid removal on hysteroscopic myomectomy. DESIGN: Multicenter, prospective study (Canadian Task Force classification II-2). SETTING: Four hysteroscopy centers in Brazil, China, Italy, and the United States. PATIENT(S): Four hundred forty-nine women who underwent hysteroscopic resection of 465 submucous fibroids. INTERVENTION(S): Resection of the submucous fibroids (hysteroscopic myomectomy). Fibroids were scored according to the European Society for Gynaecological Endoscopy (ESGE) and STEPW classifications. The validation of the two classifications was assessed using sensitivity and specificity of each classification, with their best cutoff point. A test of equality of the two areas under the receiver operating characteristic curves was performed for correlated samples. MAIN OUTCOME MEASURE(S): Correlation of ESGE and STEPW classifications with complete or incomplete removal of submucous fibroid. RESULT(S): Removal of the myoma was complete in 432 (92.9%) of 465 myomectomies and incomplete in 33 (7.1%). All 320 fibroids (100%) with a score≤4 in the STEPW classification were completely removed, and 112 of 145 fibroids (77.2%) with a score>4 were removed. All 33 cases of incomplete hysteroscopic myomectomy (100%) had a STEPW score>4. Using the ESGE classification, 85 of 86 cases (98.9%) of type 0 fibroids, 278 of 298 (93.3%) of type 1, and 69 of 81 (85.2%) of type 2 were completely resected. CONCLUSION(S): Classifying submucous fibroids using the STEPW classification permits greater correlation with complete or incomplete removal of the myoma by hysteroscopic myomectomy.